TY - JOUR
T1 - Guideline-Directed Medical Therapy Tolerability in Patients With Heart Failure and Mitral Regurgitation
T2 - The COAPT Trial
AU - Cox, Zachary L.
AU - Zalawadiya, Sandip K.
AU - Simonato, Matheus
AU - Redfors, Bjorn
AU - Zhou, Zhipeng
AU - Kotinkaduwa, Lak
AU - Zile, Michael R.
AU - Udelson, James E.
AU - Lim, D. Scott
AU - Grayburn, Paul A.
AU - Mack, Michael J.
AU - Abraham, William T.
AU - Stone, Gregg W.
AU - Lindenfeld, Jo Ann
N1 - Publisher Copyright:
© 2023 American College of Cardiology Foundation
PY - 2023/7
Y1 - 2023/7
N2 - Background: In the COAPT (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients With Functional Mitral Regurgitation) trial, a central committee of heart failure (HF) specialists optimized guideline-directed medical therapies (GDMT) and documented medication and goal dose intolerances before patient enrollment. Objectives: The authors sought to assess the rates, reasons, and predictors of GDMT intolerance in the COAPT trial. Methods: Baseline use, dose, and intolerances of angiotensin-converting enzyme inhibitors (ACEIs), angiotensin II receptor blockers (ARBs), angiotensin receptor neprilysin inhibitors (ARNIs), beta-blockers, and mineralocorticoid receptor antagonists (MRAs) were analyzed in patients with left ventricular ejection fraction (LVEF) ≤40%, in whom maximally tolerated doses of these agents as assessed by an independent HF specialist were required before enrollment. Results: A total of 464 patients had LVEF ≤40% and complete medication information. At baseline, 38.8%, 39.4%, and 19.8% of patients tolerated 3, 2, and 1 GDMT classes, respectively (any dose); only 1.9% could not tolerate any GDMT. Beta-blockers were the most frequently tolerated GDMT (93.1%), followed by ACEIs/ARBs/ARNIs (68.5%), and then MRAs (55.0%). Intolerances differed by GDMT class, but hypotension and kidney dysfunction were most common. Goal doses were uncommonly achieved for beta-blockers (32.3%) and ACEIs/ARBs/ARNIs (10.2%) due to intolerances limiting titration. Only 2.2% of patients tolerated goal doses of all 3 GDMT classes. Conclusions: In a contemporary trial population with HF, severe mitral regurgitation, and systematic HF specialist-directed GDMT optimization, most patients had medical intolerances prohibiting 1 or more GDMT classes and achieving goal doses. The specific intolerances noted and methods used for GDMT optimization provide important lessons for the implementation of GDMT optimization in future clinical trials.
AB - Background: In the COAPT (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients With Functional Mitral Regurgitation) trial, a central committee of heart failure (HF) specialists optimized guideline-directed medical therapies (GDMT) and documented medication and goal dose intolerances before patient enrollment. Objectives: The authors sought to assess the rates, reasons, and predictors of GDMT intolerance in the COAPT trial. Methods: Baseline use, dose, and intolerances of angiotensin-converting enzyme inhibitors (ACEIs), angiotensin II receptor blockers (ARBs), angiotensin receptor neprilysin inhibitors (ARNIs), beta-blockers, and mineralocorticoid receptor antagonists (MRAs) were analyzed in patients with left ventricular ejection fraction (LVEF) ≤40%, in whom maximally tolerated doses of these agents as assessed by an independent HF specialist were required before enrollment. Results: A total of 464 patients had LVEF ≤40% and complete medication information. At baseline, 38.8%, 39.4%, and 19.8% of patients tolerated 3, 2, and 1 GDMT classes, respectively (any dose); only 1.9% could not tolerate any GDMT. Beta-blockers were the most frequently tolerated GDMT (93.1%), followed by ACEIs/ARBs/ARNIs (68.5%), and then MRAs (55.0%). Intolerances differed by GDMT class, but hypotension and kidney dysfunction were most common. Goal doses were uncommonly achieved for beta-blockers (32.3%) and ACEIs/ARBs/ARNIs (10.2%) due to intolerances limiting titration. Only 2.2% of patients tolerated goal doses of all 3 GDMT classes. Conclusions: In a contemporary trial population with HF, severe mitral regurgitation, and systematic HF specialist-directed GDMT optimization, most patients had medical intolerances prohibiting 1 or more GDMT classes and achieving goal doses. The specific intolerances noted and methods used for GDMT optimization provide important lessons for the implementation of GDMT optimization in future clinical trials.
KW - COAPT trial
KW - guideline-directed medical therapy
KW - heart failure
KW - intolerance
KW - mitral regurgitation
UR - https://www.scopus.com/pages/publications/85160693779
U2 - 10.1016/j.jchf.2023.03.009
DO - 10.1016/j.jchf.2023.03.009
M3 - Article
C2 - 37115135
AN - SCOPUS:85160693779
SN - 2213-1779
VL - 11
SP - 791
EP - 805
JO - JACC: Heart Failure
JF - JACC: Heart Failure
IS - 7
ER -